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58 - Critical and intensive care ethics
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- By Philip D. Levine, Attending Physician Department of Anesthesiology and Critical Care Medicine Hadassah Hebrew University Hospital Jerusalem, Israel, Charles L. Sprung, Professor of Medicine and Critical Care Medicine Hadassah University Hospital Jerusalem, Israel
- Edited by Peter A. Singer, University of Toronto, A. M. Viens, University of Oxford
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- Book:
- The Cambridge Textbook of Bioethics
- Published online:
- 30 October 2009
- Print publication:
- 31 January 2008, pp 462-468
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- Chapter
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Summary
A 70-year-old male patient (Patient E) is admitted to the intensive care unit (ICU) following a road traffic accident in which he suffered severe head and abdominal injuries. After four weeks in the ICU, the patient's neurological condition has stabilized with minimal function (the patient does not communicate but withdraws all four limbs to painful stimuli). Following numerous bouts of sepsis, the patient is developing renal failure. He is anuric, hyperkalemic, and acidotic. He is also ventilator dependent and on high doses of inotropes. The patient's family states that in their culture, life continues until the heart stops beating. The family (that includes a physician) requests that all resuscitative efforts be continued, including dialysis.
In parallel, a second patient (Patient F) with similar injuries, but with metastatic prostate cancer, is admitted to the emergency room and requires an ICU bed. In addition to his traumatic injuries, however, he is wheel-chair bound as a result of dementia. No beds are currently available. According to the assessment of the ICU physician attending, the trauma patient described in case one has the least to benefit from ICU therapy and should be assessed for withdrawal of ventilation, to which the family strenuously objects.
What is critical and intensive care ethics?
Many aspects of medical care practiced today would not be feasible without the support of an intensive care unit (ICU).
Assessing the in-hospital survival benefits of intensive care
- Amir Shmueli, Charles L. Sprung
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- Journal:
- International Journal of Technology Assessment in Health Care / Volume 21 / Issue 1 / January 2005
- Published online by Cambridge University Press:
- 02 March 2005, pp. 66-72
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- Article
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Objectives: For an efficient and fair allocation of medical resources, one must know which patients benefit more from medical care. The objective of this study is to assess the differential survival benefits of a general intensive care unit (ICU) by acute diagnoses and by Acute Physiological and Chronic Health Evaluation (APACHE II) scores.
Methods: The sample included all patients triaged for admission to the Hadassah-Hebrew University Medical Center ICU during a 7-month period (n = 381). The potential effect of ICU on in-hospital survival was estimated by a bivariate (admission–survival) probit model, using crowding in the unit as the identifying variable, controlling for observable patients characteristics: age, sex, acute diagnoses, and APACHE II score. Using the estimates, the differential predicted survival benefits of ICU were calculated for selected general acute diagnoses and for different APACHE II scores.
Results: Adjusting for age, sex, and general acute diagnoses, the average potential survival benefit of ICU is 17 percentage points (pts). The benefit of ICU for patients with central nervous system problems, with sepsis, or with respiratory failure are higher than average (23 pts). Adjusting for APACHE II scores as well increases the estimated average potential benefit to 21 pts. Over the range of APACHE II scores, the highest benefit (38 pts of potential benefit) is attained for patients with scores around 22.
Conclusions: Survival benefits differ across diagnoses and APACHE II scores. Facing limited resources, admission policies should distinguish between survival probabilities (and survival maximization) and survival benefits (and maximization of ICU benefits). Actual referral and admission policies to the present ICU do not maximize the potential survival benefits of ICU resources.
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